1. BEST PRACTICES FOR TRANSITIONAL CARE

Patients Should Request their Medical Records

• When transitioning from one physician to another, patients need to request their medical records, which should help the new doctor understand their conditions fast. Importantly, they ought to inform their health insurance provider of the change.
• Patients have a right to their medical records and can get them from their previous doctor’s office by filling out an authorization form. Moreover, they are not obligated to explain to anyone why they are switching doctors unless they want to share their previous medical experiences.
• Regarding the transfer of patients’ records, the previous provider can forward them to the new PCP on behalf of the patient, and the transfer usually takes about 30-60 days.
• Doctors participating in the Medicare and Medicaid Electronic Health Care Record Incentive Program can receive the records within four business days. Thus, patients need also to confirm whether the new doctor participates in the program.

Hospital Transitional Care Clinics

• With Medicare readmission penalties forcing hospitals to introduce transitional care clinics (TCCs) catering to patients recently discharged and those from the inpatient setting, these TCCs can facilitate patient transfer from one doctor to another, especially when the doctors/hospitals are part of a network.
• According to a Northwestern Medical Group Transitional Care Clinic (NMG-TC) study, TCCs also help increase the “proportion of low-income, medically complex patients."
• The study, published in ‘The Joint Commission Journal on Quality and Patient Safety’ revealed that increasing referrals would highly depend on the “automation of referral guidelines and improved transitional care education.” NMG-TC also found out that increasing patient engagement also depended on highlighting nonmedical offerings and warm handoffs.
• Equally, electronic health records (EHR) data showed that “male, uninsured, non-Hispanic black, or homeless; had documented substance use; or lived > 50 miles from the clinic” were the most likely to miss appointments. In contrast, individuals with anxiety, heart failure, or malignancy conditions were the least likely to miss appointments.
• Overall, the study concluded that TCCs could boost transition care rates via improved communication of the benefits TCCs offer patients and referring providers, including warm appointment handoffs for those patients likely to miss appointments.

Using Local Care Coordinators

• Patients can work with various transition coordinators, including discharge planners, nurse navigators, and case managers, to find their next PCP or care setting. These individuals deliver ongoing care for the patients at every stage of the transition process.
• The transition team focuses on various roles, including but not limited to transition and discharge planning, education, and communication of planned treatment and aftercare, among others. The team also accesses patient information shared across the care continuum, including the patient and their caregivers.
• Local care coordinators act as a patient’s supporter and an enabler for the care team. They are supported in their roles by regional care coordinators who rely on a centralized data system. Care coordinators strictly identify and engage high-risk (cost) patients and link them with primary care providers and community-based services.
• Overall, care coordinators establish connections for PCPs and high-need patients and exchange their medical history with the new PCP to successfully transition them from one care setting to another.

2. CASE STUDIES ON PROGRAMS TO IMPROVE DOCTOR-PATIENT RELATIONSHIPS

Telemedicine Programs

• Physicians are used to seeing and treating patients in-person; however, technology-enabled solutions like telemedicine solutions simplify the doctor-patient relationship. The use of live video communication has proven effective in offering an in-person like experience.
• Telemedicine technologies are evolving fast, and the latest telehealth solutions feature advanced programs and tools that replicate the in-person experience. The features include “high-definition live video and clear audio,” enabling the care provider to see and easily communicate with their patients in real-time using a reliable internet connection.
• These advanced capabilities allow doctors to diagnose symptoms accurately and address many health problems like flu, ashes, common aches, follow-up appointments, etc. Likewise, telehealth solutions increase the frequency of doctor-patient communication allowing both parties to share and access medical records data when they need it most.
•  Reducing the doctor-patient distance can improve the doctor-patient relationship, considering patients will be more willing to keep their appointments and show more commitment towards contacting their doctors to avoid taking time off work to visit the doctor’s office. Telehealth tools also allow doctors to increase patient communication as they can set reminders and updates in real-time to guide patients on medication, scheduling appointments, or quick consultations.
• The University of Arizona is an example of an institution with a telemedicine program designed to improve the doctor-patient relationship and focus on limited physician services areas. In Touch Health is also an example of a telehealth technology vendor providing solutions to improve the doctor-physician relationship, physician capacity management, etc.

Concierge & Direct Care Programs — Robinson MD

• The Robinson MD Concierge & Direct Care Program is a “relationship-based model based on open communication and physician accessibility” to enhance the physician-patient relationship and care delivery.
• Concierge medicine fosters the direct connection between doctors and patients, which improves care delivery in a complete and personalized way. The program allows physicians to act as a patient’s advocate without interference from outside parties, including the insurance system.
• Unlike the typical hospital setting where patients feel that the level of medical care has suffered, quantity supersedes quality, and doctors lack time for patients’ most pressing needs, concierge programs combat those inadequacies in the current healthcare setup by delivering accessible, personalized, and superior care to patients.
• The concierge program ensures patients access a more knowledgeable physician who also provides them with personalized attention. The plan includes “24/7 access to a personal physician via cell phone, e-mail, and texting; priority scheduling for appointments; access to the best specialists and resources; an individualized written health action plan; and a more holistic approach to care. "
• Robinson MD's Concierge & Direct Care Program targets all patients covered in its various service offerings. The care program has three annual plan structures, with the essential direct care plan costing $1,500, a wellness plan for $2,500, and a comprehensive plan for $3,500.

Research Methodology